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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM " �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E-]6 TEMPORARY SITE CLOSURE O w <br /> N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) __4 <br /> FACILITY/SITE NAME n CARE OF AQSS INFORM <br /> DREATION <br /> Lo&i ((/10 IT m'I le <br /> ADDRESS ( ( NEAREST CROSS STREET ✓Em birduo D PARTNERSHIP [I STATE AGENCY <br /> S U OY GY S"\ D CORPWTIIXD LAGE#CY FALAGENLY <br /> D INDWDUAL D CIDUNTY- L <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> CA 33-( S /,/-/ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bw if INDIAN EPA ID # #of TANK'Y /l / 1 <br /> E] I GAS STATION E] 3 FARM THER TRUSTYATION LANDS OT ❑ AT THIS SITE v V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 20, II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY 10 If If of TANKS at SITE <br /> ® = = I do I o <br /> CURRENT LOCAL AGENCY FACILITY ID# LO D l e,5 a APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD CENSUS TRACT N� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED 0 <br /> zJ QI YES NO �5 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-BB) • • <br /> t I DATA PROCESSING COPY <br />